Provider Demographics
NPI:1124057989
Name:LEE KIDNEY CENTER PA
Entity type:Organization
Organization Name:LEE KIDNEY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GANESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHENOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-303-2820
Mailing Address - Street 1:14181 S TAMIAMI TRL STE 120A
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1985
Mailing Address - Country:US
Mailing Address - Phone:239-303-2820
Mailing Address - Fax:239-303-2511
Practice Address - Street 1:14181 S TAMIAMI TRL STE 120A
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1985
Practice Address - Country:US
Practice Address - Phone:239-303-2820
Practice Address - Fax:239-303-2511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84882207RN0300X
207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K8190Medicare PIN
DD9499Medicare PIN